Purpose: This study evaluated the predictive value of intraoperative graft flow measurement using the Medistim VeriQ™ system in paramalleolar bypass for chronic limb-threatening ischemia (CLTI), incorporating the Inframalleolar/Pedal Descriptor (IMPD) classification as a marker of pedal arterial complexity. Methodology: A total of 165 inframalleolar bypasses were performed between 2014 and 2019. Target vessels were selected based on angiographic run-off, lateral foot radiographs for arterial calcification, and intraoperative ultrasonography. Graft flow was measured using the VeriQ™ transit-time flowmeter after anastomosis. Pedal anatomy was classified using the IMPD system (P0–P2). ROC analysis identified thresholds for early intervention. Patients with intraoperative flow <20 mL/min received intra-graft vasodilators; refractory cases underwent catheter-based postoperative infusion. Multivariate analysis determined predictors of early (≤30 days), intermediate (≤3 months), and long-term outcomes. Results: Mean flow values were 52 ± 26 (P0), 49 ± 41 (P1), and 33 ± 30 mL/min (P2) (P=0.20). Early reintervention occurred in 4% (P0), 6% (P1), and 33% (P2). Two-year primary/secondary patency rates were 58%/100% (P0), 53%/84% (P1), and 22%/70% (P2). Flow <25 mL/min (OR: 3.4) and P2 anatomy (OR: 10.4) predicted early failure. For 3-month intervention, flow <40 mL/min (OR: 4.0) and P2 lesions (OR: 10.9) were significant. Long-term failure was associated with poor vein quality (HR: 2.1), chronic heart failure (HR: 1.9), and P2 anatomy (HR: 6.6). Conclusion: Intraoperative graft flow measured by the VeriQ™ system helps predict early graft intervention after paramalleolar bypass. Thresholds of <25 and <40 mL/min identify patients at immediate and intermediate risk, and IMPD-based stratification further supports informed surgical decision-making.